The document discusses the female reproductive system. It summarizes that the female reproductive system regulates hormonal changes responsible for puberty and reproduction through dynamic interactions between the hypothalamus, pituitary gland, and ovaries. This results in repetitive cycles of follicle development, ovulation, and preparation of the uterine lining for potential implantation. The document then goes on to describe the anatomy and blood supply of the external and internal female genital organs.

1. GUIDE:-Dr. Gayatri.B.H
STUDENT:-Dr.Geeta.chintamani

2.  The female reproductive system regulates the
hormonal changes responsible for puberty and
adult reproductive function.
 Normal reproductive function in women requires
the dynamic integration of hormonal signals
from the hypothalamus, pituitary, and ovary.
 Resulting in repetitive cycles of follicle
development, ovulation, and preparation of the
endometrial lining of the uterus for implantation
should conception occur.

3.  EXTERNAL GENITAL
ORGANS
 Mons pubis
 Labia majora
 Labia minora
 Clitoris
 Vestibule
 Bartholin’sglands
 INTERNAL GENITAL
ORGANS
 Vagina
 Uterus
 Fallopian tubes
 Ovaries
 Urethra

5.  Anterior division of internal iliac artery
 Ovarian artery
 Superior rectal artery.
 Uterine artery arises either directly from the
internal iliac artery or in common with the
obliterated umbilical artery
 Vaginal artery
 Internal pudendal artery

6.  There is a tendency to form plexuses
 The plexuses anastomose freely with each
other
 The veins may not follow the course of the
artery
 They have no valves.

7.  Venous drainage from the uterine, vaginal
and vesical plexuses chiefly drain into
internal iliac vein.
 Ovarian veins drains into left renal vein on
the left side and inferior vena cava on the
right side

8.  The neuroendocrine mechanisms are the
basic factors in the reproductive cycle.
 The hypothalamus produces a series of
specific releasing and inhibiting hormones
which have got effect on the production of
the specific pituitary hormones

9.  GnRH is secreted by the arcuate nucleus of the
hypothalamus in a pulsatile fashion
 GnRH is a decapeptide and is concerned with the
release, synthesis and storage of both the
gonadotropins (FSH and LH) from the anterior
pituitary.
 The half-life of GnRH is very short (2–4 minutes).
 GnRH stimulates anterior pituitary for synthesis,
storage and secretion of gonadotropins.
 Down regulation
 Up -regulation

10.  Neurotransmitters and neuromodulators.
 Peptides.
 Ultrashort feedback loop.
 Short feedback loop.
 Long feedback loop.

13.  Two gonadotropic hormones secreted from
the anterior pituitary—
1. Follicle stimulating hormone (FSH) and
2. Luteinizing hormone (LH).
 FSH and LH are secreted from the beta cells in
a pulsatile fashion in response to pulsatile
GnRH.
 These are water-soluble glycoproteins.

14.  The growth and maturation of the Graafian
follicle. In conjunction with LH, it is also involved
in maturation of oocyte, ovulation and
steroidogenesis.
 The FSH level tends to rise soon following the
onset of menstruation and attains its peak at the
12th day of the cycle (preovulatory) and gradually
declines to attain the base level at about the 18th
day

15.  FSH rescues follicles from apoptosis.
 Stimulates formation of follicular vesicles.
 Stimulates proliferation of granulosa cells.
 Helps full maturation of the Graafian follicle
(dominant follicle) as it converts the follicular
microenvironment from androgen dominated
to estrogen dominated

16.  Synthesizes its own receptors in the granulosa
cells.
 Synthesizes LH receptors in the theca cells.
 Synthesizes LH receptors in the granulosa cells.
 Induces aromatization to convert androgens to
estrogens in granulosa cells .
 Enhances autocrine and paracrine function (IGFII,
IGF-I) in the follicle.
 Stimulates granulosa cells to produce activin and
inhibin.
 Stimulates plasminogen activator necessary for
ovulation.

17.  Activation of LH receptors in the theca cells
which stimulates the enzymes necessary for
androgen production → diffuse into the
granulosa cells → estrogens
 Luteinization of the granulosa cells → to
secrete progesterone.
 Synthesizes prostaglandins.

18.  Stimulates resumption of meiosis with extrusion
of first polar body .
 Helps in the physical act of ovulation .
 Formation and maintenance of corpus luteum.
 LH levels remain almost static throughout the
cycle
 At least 12 hours prior to ovulation, it attains its
peak, called LH surge

19.  The principal hormones secreted from the
ovaries are—
1. Estrogen
2. Progesterone
3. Androgens
4. Inhibin.

20.  The estrogen is predominantly estradiol (E2) and to
a lesser extent estrone.
 During the follicular phase, under the influence of
LH, androgens (androstenedione and testosterone)
are produced in the theca cells.
 These androgens diffuse into the granulosa cells
where they are aromatized under the influence of
FSH to estrogens—estradiol predominantly and to
lesser extent estrone

21.  Estrogen tends to induce feminine
characteristics.
 Estrogen increases the coagulability of blood
by increasing many procoagulants, chiefly
fibrinogen. The platelets become more
adhesive.
 Estrogen conserves calcium and phosphorus
and encourages bone formation.

22.  Estrogen increases sodium, nitrogen and fluid
retention of the body.
 It lowers the blood cholesterol and lowers the
incidence of coronary heart disease in women
prior to menopause.

24.  Congenital malformations of female genital
organs.
 Disorders of puberty.
 Disordres of sexual development
 Pelvic infections ,STDs.
 Dysmenorrhea & disorders of menstrual cycle
 Infertility
 Abnormal utrine bleeding & amenorrhea
 Benign lesions of female genital organs
 Premalignant lesions
 Genital malignancy
 Genital tract injuries & anorectal malformations

25.  Precocious puberty
 •Delayed puberty
 •Menstrual abnormalities (amenorrhea,
menorrhagia, dysmenorrhea)
 •Others (infection, neoplasm, hirsutism, etc

26.  The term precocious puberty is reserved for
girls who exhibit any secondary sex
characteristics before the age of 8 or
menstruate before the age of 10.

27.  GnRH dependent—80% (complete, central,
isosexual or true)
 constitutional—most common
 Juvenile primary hypothyroidism
 Intracranial lesions—trauma, tumor or
infection
 Incomplete
 Premature thelarche
 Premature puberche
 Premature menarche

28.  GnRH independent (precocious pseudopuberty or
peripheral) (excess estrogen or androgen)
 Ovary
 Granulosa cell tumor
 Theca cell tumor
 Leydig cell tumor
 Chorionic epithelioma
 Androblastoma
 Mccune -albright syndrome
 Adrenal
 Hyperplasia
 Tumor

29.  Liver
 Hepatoblastoma
 Iatrogenic
 Estrogen or androgen intake

30.  True precocious
 Constitutional type is the commonest one but
the rare one is to be kept in mind.
 The diagnosis is made by:
 History of early menarche of mother and
sisters
 The pubertal changes occur in orderly
sequence
 Tanner stages
 No cause could be detected.

31.  Pelvic sonography to exclude ovarian pathology
 Skull X-ray, CT scan, or MRI brain—to exclude
intracranial lesion
 Serum hCG, FSH, LH
 Thyroid profile
 Serum estradiol, testosterone, 17 OH
progesterone, dehydroepiandrosterone (DHEA)
 GnRH stimulation test.
 X-ray hand and wrist for bone age.

32.  GnRH agonist therapy arrests the pubertal
precocity and growth velocity significantly. The
agonists suppress the premature activation of
hypothalamopituitary axis due to down
regulation and thereby diminished estrogen
secretion.
1. Buserelin nasal spray 100 mg daily.
2. Goserelin or leuprolide once a month can be
used.

33.  Medroxyprogesterone acetate—30 mg daily orally
or 100–200 mg. IM weekly to suppress gonadal
steroids. It can suppress menstruation and breast
development but cannot change the skeletal
growth rate.
 Cyproterone acetate—It acts as a potent
progestogen, having agonist effects on
progesterone receptors.
 Dose—70–100 mg/m2/day orally for 10 days
starting from 5th day of cycle.

34.  Puberty is said to be delayed when the breast
tissue and/or pubic hair have not appeared
by 13–14 years or menarche appears as late
as 16 years.

35.  Hypergonadotropic hypogonadism
 Gonadal dysgenesis, 45 xo
 Pure gonadal dysgenesis 46 xx, 46 xy
 ovarian failure 46 xx
 Hypogonadotropic hypogonadism
 Constitutional delay
 Chronic illness, malnutrition
 Primary hypothyroidism
 Isolated gonadotropin deficiency
 Intracranial lesions—tumors:
 craniopharyngioma, pituitary adenomas

36.  Eugonadism
 Müllerian agenesis
 Imperforate hymen
 Transverse vaginal septum
 Androgen insensitivity syndrome

37.  Hypogonadism may be treated with cyclic
estrogen. Unopposed estrogen 0.3 mg daily is
given for first 6 months.
 Then combined estrogen and progestin,
sequential regimen is started .
 Hypergonadotropic hypogonadism should
have chromosomal study to exclude
intersexuality

38.  Infections , which are predominantly transmitted
through sexual contact from an infected partner.
 The transmission of the infections:-
 Sexual contact
 Placental (HIV, syphilis)
 Blood transfusion
 Infected needles (HIV, hepatitis B or syphilis),
 Birth canal (gonococcal, chlamydial, or herpes)

39.  The causative organism is Neisseria
gonorrheae — a Gram-negative diplococcus.
 The incubation period is 3–7 days.
 The primary sites of infection are endocervix,
urethra, Skene’s gland, and Bartholin’s gland.
The organism may be localized in the lower
genital tract to produce urethritis,
bartholinitis, or cervicitis

40.  Urinary symptoms such as dysuria (25%)
 Excessive irritant vaginal discharge (50%)
 Acute unilateral pain and swelling over the
labia due to involvement of Bartholin’s gland
 There may be rectal discomfort due to
associated proctitis from genital contamination
 Others: Pharyngeal infection, intermenstrual
bleeding.

41.  Labia may be swollen and look inflamed
 The vaginal discharge is mucopurulent
 The external urethral meatus and the
openings of the Bartholin’s ducts look
congested.
 squeezing the urethra and giving pressure on
the Bartholin’s glands, purulent exudate
escapes out through the openings.
 Bartholin’s gland may be palpably enlarged,
tender with fluctuation, suggestive of
formation of abscess.

42.  Septicemia is characterized by low grade
fever, polyarthralgia, tenosynovitis, septic
arthritis, perihepatitis, meningitis,
endocarditis, and skin rash.
 Chronic pelvic inflammatory disease,
 Infertility,
 Ectopic pregnancy (due to tubal damage),
 Dyspareunia
 Chronic pelvic pain,
 Tubo -ovarian mass, and
 Bartholin’s gland abscess

43.  Nucleic acid amplication testing (NAAT) of
urine or endocervical discharge.
 NAAT is very sensitive and specific (95%).
 In the acute phase, secretions from the
urethra, Bartholin’s gland, and endocervix are
collected for Gram stain and culture

44.  Ceftriaxone — 125 mg im
 Ciprofloxacin — 500 mg Po
 ofloxacin — 400 mg Po
 Cefixime — 400 mg Po
 levofloxacin — 250 mg Po

45.  Syphilis is caused by the anaerobic spirocheta
Treponema pallidum.
 Incubation period 9-90days

46.  The primary lesion (chancre) may be single or
multiple and is usually located in the labia.
 Fourchette, anus, cervix, and nipples are the
other sites of lesion.
 A small papule is formed, which is quickly
eroded to form an ulcer.
 The margins are raised with smooth shiny floor.
The ulcer is painless without any surrounding
inflammatory reaction.
 The inguinal glands are enlarged, discrete, and
painless.

47.  Secondary syphilis—Within 6 weeks to 6
months from the onset of primary chancre,
 The secondary syphilis may be evidenced in
the vulva in the form of condyloma lata.
 These are coarse, flat-topped, moist, necrotic
lesions and teeming with treponemes.
 Patient may present with systemic symptoms
like fever, headache, and sore throat.
 Maculopapular skin rashes are seen on the
palms and soles.
 Generalized lymphadenopathy, mucosal
ulcers, and alopecia

48.  Latent syphilis — It is the quiescence phase after
the stage of secondary syphilis has resolved.
duration from 2 to 20 years.
 Tertiary syphilis — About one third of untreated
patients progress from late latent stage to tertiary
syphilis.
 It damages the central nervous, cardiovascular, and
musculoskeletal systems.
 Cranial nerve palsies (III, VI, VII, and VIII),
hemiplegia, tabes dorsalis, aortic aneurysm, and
gummas of skin and bones.
 The important pathology is endarteritis and
periarteritis of small and medium sized vessels.
 A gummatous ulcer is a deep punched ulcer with
rolled out margins. It is painless with a moist
leather base.

49.  Dark ground illumination through a microscope.
 Serological tests:
 (a) VDRL: is positive after 6 weeks of initial
infection.
 (b) The specific tests include Treponema
pallidum hemagglutination (TPHA) test,
Treponema pallidum enzyme immunoassay (EIA),
fluorescent treponemal antibody absorption
(FTA-abs) test and Treponema pallidum
immobilization (TPI) test

50.  Fluorescent treponemal antibody absorption
test (FTA-abs). FTA-abs is expensive but a
confirmatory test. FTA-IgM is produced only
in active treponemal infection and it declines
after adequate treatment
 VDRL and TPHA tests are used for screening
and FTA-abs test is used for confirmation.
 Currently immunoblotting and PCR tests are
evaluated as more sensitive and confirmatory
tests.

51.  Early syphilis (primary, secondary, and early
latent syphilis of less than 1 year duration)
 Benzathine penicillin G 2.4 million units is
given intramuscularly in a single dose, half to
each buttock.
 In penicillin allergic cases, tetracycline 500 mg,
4 times a day or Doxycycline 100 mg BID PO
for 14 days is effective.

52.  Late syphilis: Benzathine penicillin G 2.4
million units is given IM weekly for 3 weeks
 Alternative regimen: Doxycycline 100 mg
orally twice daily or Tetracycline 500 mg
orally 4 times a day for 4 weeks.

53.  Chlamydia trachomatis (of D-K serotypes), an
obligatory intracellular Gram-negative
bacteria.
 Incubation period 6-14days

54.  Non-specific and asymptomatic in most cases
(75%).
 Dysuria, dyspareunia, postcoital bleeding,
and intermenstrual bleeding are the
presenting symptoms.
 Mucopurulent cervical discharge, cervical
edema, cervical ectopy, and cervical friability.

55.  Urethritis and bartholinitis
 Chlamydial cervicitis spreads upwards to
produce endometritis and salpingitis.
 It causes tubal scarring resulting in infertility
and ectopic pregnancy.
 Perihepatitis

56.  Chlamydial nucleic acid amplification testing
and detection by polymerase chain reaction
(PCR) is a very sensitive and specific test
(95%).
 ELISA
 Chlamydia can be demonstrated in tissue
culture. (McCoy cell monolayers). It is 100%
specific. It takes 3–7 days to obtain result

57.  Azithromycin — 1 g orally single dose or
 ™Doxycycline — 100 mg orally bid × 7 days or
 ™Ofloxacin — 200 mg orally bid × 7 days or
 ™Erythromycin — 500 mg orally bid × 7 days.

58.  Causative organism is a Gram-negative
streptobacillus— Hemophilus ducreyi.
 The incubation period is very short 3–5 days
or less

59.  The lesion starts as multiple vesicopustules
over the vulva, vagina or cervix.
 It then sloughs to form shallow ulcers
circumscribed by inflammatory zone.
 The lesion is very tender with foul purulent
and hemorrhagic discharge. There may be
cluster of ulcers.
 Unilateral inguinal lymphadenitis may occur
which may suppurate to form abscess
(buboes)

60.  Demonstration of Ducreyi bacillus in
specialized culture media is confirmatory.
 Discharge from the ulcers or pus from the
lymph glands is taken for culture. In the
stained film (Gram stain) the organisms
appear classically as ‘Shoal of fish’.

61.  Ceftriaxone 250 mg IM single dose
 ••Azithromycin 1 gm by single dose.
 ••Erythromycin 500 mg by every 6 hours for 7
days can also be given.

62.  Lymphogranuloma venereum (LGV) is caused
by one of the aggressive L serotypes of
Chlamydia trachomatis usually acquired
sexually.
 Incubation period is 3–30 days.

63.  Initial lesion is a painless papule, pustule or
ulcer in the vulva, urethra, rectum or the
cervix.
 Inguinal nodes are involved and feel rubbery.
There is acute lymphangitis and
lymphadenitis.
 The glands become necrosed and abscess
(bubo) forms.
 7–15 days, the bubo ruptures and results in
multiple draining sinuses and fistulas.

64.  The secondary phase is noted by painful
adenopathy.
 The classical clinical sign of LGV is the
“groove sign”, a depression between the
groups of inflamed nodes.
 The lymphatic obstruction leads to vulval
swelling where as lymphatic extension to the
vulva, vagina, or rectum leads to ulceration,
fibrosis, and stricture of the vagina or
rectum.

65.  Vulval elephantiasis,
 Perineal scarring and dyspareunia,
 Stricture , and
 Sinus and fistula formation

66.  Culture and isolation (Lymph node aspiration)
of LGV (Chlamydia serotypes L1,2,3) is
confirmatory.
 Detection of LGV antigen in pus obtained
from a bubo with specific monoclonal
antibodies using immunofluorescence
method.
 Detection of LGV antigen by ELISA method
 LGV complement fixation test—when positive
with rising titer (>1 : 64).

67.  Definitive treatment—
 Doxycycline 100 mg BID for at least 21 days.
 Azithromycin 1 g PO weekly for 3 weeks or
Erythromycin 500 mg orally every 6 hours for 21
days is given (indicated for pregnant women).
 Surgical—Abscess should be aspirated but not
be excised.
 Manual dilatation of the stricture weekly. It is
essential to use antibiotics during the
perioperative period.

68.  Causative organism is Gram-negative
intracellular bacillus—Calymmatobacterium
granulomatis (Donovania granulomatis).

69.  The lesion starts as pustules, which
breakdown and erode the adjacent tissues
through continuity and contiguity.
 The ulcer looks hypertrophic (beefy red) The
margins are rolled and elevated.

70.  Donovan bodies within the mononuclear cells
in material (scrapings) from the ulcer when
stained by the Giemsa method.
 Donovan bodies are clusters of dark-staining
bacteria with a bipolar (safety pin)
appearance found within the mononuclear
cells.

71.  Doxycycline 100 mg BID for at least 3 weeks.
 Ciprofloxacin 750 mg BID for at least 2
weeks

72.  The causative organisms present concept is that
along with G vaginalis, anaerobic organisms
such as Bacteroides species, Peptococcus
species, mobiluncus, and Mycoplasma hominis
act synergistically to cause vaginal infection.
 There is marked decrease in lactobacilli

73.  Bacterial Vaginosis (BV) is characterized by
malodorous vaginal discharge.
 The discharge is homogeneous, greyish-
white and adherent to the vaginal wall.
 In pregnancy - preterm rupture of
membranes, preterm labor, and
chorioamnionitis.

74.  Recurrent infection leading to PID.
 vaginal cuff cellulitis following hysterectomy
 Pregnancy complications: second trimester
miscarriage, PROM, preterm birth,
endometritis

75.  Amsel’s four diagnostic criteria are:
 (1) Homogeneous vaginal discharge.
 (2) Vaginal pH > 4.5 (litmus paper test).
 (3) Positive whiff tests
 (4) Presence of clue cells (> 20% of cells).
 (B) Gram stained vaginal smear (Hay/Ison):
 Presence of more Gardnerella or mobiluncus
morphotypes with few or absent lactobacilli.

76.  Metronidazole — 200 mg orally thrice daily
for 7 days.
 Clindamycin cream (2%) and metronidazole
(0.75%) gel are recommended for vaginal
application daily for 5 days to prevent
obstetric complications.

77.  The causative organism is herpes simplex
virus (HSV) type 1 and 2.
 The incubation period is 2–14 days.

78.  Red painful inflammatory area appears
commonly on the clitoris, labia, vestibule,
vagina, perineum ,and cervix.
 Multiple vesicles appear which progress into
multiple shallow ulcers and ultimately heal up
spontaneously by crusting.
 Inguinal lymphadenopathy
 Constitutional symptoms include fever,
malaise, and headache.
 vulvar burning, pruritus, dysuria, or retention
of urine

79.  Virus tissue culture and isolation is
confirmatory.
 Detection of virus antigen by ELISA or
immunofluorescent method.
 PCR test to identify the HSV DNA is the rapid,
specific, and most accurate test.

80.  Increased risks of miscarriage and pre-term
labor.
 Transfer of infection from mother to neonates
during vaginal delivery, if primary (50%) or
recurrent (5%).
 Baby may suffer from damage to central
nervous system.
 Delivery by cesarean section is indicated with
primary genital herpes infection at the time of
delivery.

81.  Acyclovir which inhibits the intracellular
synthesis of DNA by the virus, orally in doses
of 200 mg 5 times a day for 5 days.
 Valaciclovir 500 mg BID for 5 days
 Famciclovir 250 mg orally thrice daily for 5
days can be used alternatively.

82.  Pelvic inflammatory disease (PID).
 Following delivery and abortion.
 Following gynecological procedures.
 Following IUD.
 Secondary to other infections—appendicitis

83.  PID is a disease of the upper genital tract.
 It is a spectrum of infection and inflammation
of the upper genital tract organs typically
involving the uterus (endometrium), fallopian
tubes, ovaries, pelvic peritoneum and
surrounding structures

84.  Menstruating teenagers.
 Multiple sexual partners.
 Absence of contraceptive pill use.
 Previous history of acute PID.
 IUD users.
 Area with high prevalence of sexually
transmitted diseases.

85.  The primary organisms are ;-N. gonorrhoeae
in 30%, Chlamydia trachomatis in 30 %and
Mycoplasma hominis in 10 %.
 The secondary organisms :-
 Aerobic organisms—non-hemolytic
streptococcus. E. coli, group B streptococcus
and staphylococcus.
 Anaerobic organisms—Bacteroides species –
fragilis and bivius, peptostreptococcus and
peptococcus

86.  Bilateral lower abdominal and pelvic pain
 ••Fever, lassitude and headache.
 ••Irregular and excessive vaginal bleeding is
usually due to associated endometritis.
 ••Abnormal vaginal discharge which becomes
purulent and or copious.
 ••Nausea and vomiting.
 ••Dyspareunia.
 ••Pain and discomfort in the right hypochondrium
due to concomitant perihepatitis

87.  Abdominal palpation reveals tenderness on
both the quadrants of lower abdomen.
 The liver may be enlarged and tender.
 ••Vaginal examination reveals:-
 Abnormal vaginal discharge which may be of
purulent.
 Congested external urethral meatus or
openings of Bartholin’s ducts through which
pus may be seen escaping out on pressure.

88.  Speculum examination shows congested
cervix with purulent discharge from the canal.
 Bimanual examination reveals bilateral
tenderness on fornix palpation, which
increases more with movement of the cervix.
There may be thickening or a definite mass
felt through the fornices.

89.  Minimum Criteria
1. Lower abdominal tenderness.
2. Adnexal tenderness.
3. Cervical motion tenderness.
 ••Additional Criteria
1. Oral temperature > 38.3°C.
2. Mucopurulent cervical or vaginal discharge.
3. Raised C-reactive protein and/or ESR.
4. Laboratory documentation of positive cervical
infection with Gonorrhoea or C. trachomatis.

90.  Definitive Criteria
1. Histopathologic evidence of endometritis on
biopsy.
2. Imaging study (TVS/MRI) evidence of
thickened fluid filled tubes ± tubo-ovarian
complex.
3. Laparoscopic evidence of PID .

91.  Immediate:
 Pelvic peritonitis or generalized peritonitis.
 Septicemia—producing arthritis or myocarditis.
 Late:
 Dyspareunia.
 Infertility
 Chronic pelvic inflammation .
 Formation of adhesions or hydrosalpinx or
pyosalpinx and tubo-ovarian abscess.
 Chronic pelvic pain and ill health.
 Increased risk of ectopic pregnancy

92.  The material is collected is subjected to Gram
stain and culture (aerobic and anaerobic).
 Leucocytosis >10000cells
 Elevated ESR >15mm
 Laproscopy is gold std
 Usg abdomen
 Culdocentesis: Aspiration of peritoneal fluid
and its white cell count, if exceeds 30,000
per mL

93.  Patient should have oral therapy for 14 days
 „Regimen a
 levofloxacin 500 mg (or, ofloxacin 400 mg) Po
once daily with or without – Metronidazole 500
Po bid
 „Regimen b
 Ceftriaxone 250 mg iM single dose PlUS
Doxycycline 100 mg Po bid with or without
Metronidazole 500 mg Po bid for 14 days

94.  Suspected tubo-ovarian abscess
 Severe illness, vomiting, temperature > 38°C
 Uncertain diagnosis—where surgical
emergencies,(e.g. appendicitis) cannot be
excluded
 Unresponsive to outpatient therapy for 48 hours
 Intolerance to oral antibiotics
 Co-existing pregnancy
 Patient is known to have Hiv infection

95.  Regimen a
 „Cefoxitin 2 gm iv every 6 hours for 2-4 days +„
Doxycycline 100 mg Po for 14 days
 Regimen b
 „Clindamycin 900 mg iv every 8 hours+
Gentamicin 2 mg/kg iv (loading dose), followed by
1.5 mg/kg iv (maintenance dose) every 8 hours
 Alterntive regimen
 „levofloxacin 500 mg iv once daily with or without
Metronidazole 500 mg iv every 8 hours

96.  Generalized peritonitis.
 Pelvic abscess.
 Tubo-ovarian abscess which does not
respond (48–72 hours) to antimicrobial
therapy.

97.  Incidence is high (5–10%) amongst the patients
with infertility
 10 %of women with pelvic tuberculosis, have
urinary tract tuberculosis.
 Genital tuberculosis is almost always secondary
to primary infection such as lungs (50%), lymph
nodes, urinary tract, bones and joints.
 The fallopian tubes are invariably the primary
sites of pelvic tuberculosis.

98.  Weakness, low grade fever, anorexia, anemia or
night sweats .
 The lesion is accidentally diagnosed during
infertility or dysfunctional uterine bleeding
called “silent tuberculosis”.
 Infertility: It may be primary or secondary and
is present in about 70–80 % cases of pelvic
tuberculosis.

99.  Menstrual abnoramality:-50%. Menorrhagia or
irregular bleeding .
 ••Amenorrhea or oligomenorrhea
 Chronic pelvic pain in 20-30% cases
 Vaginal discharge—cervical or vaginal tuberculosis
may be associated with postcoital bleeding or
blood stained discharge.

100.  Per abdomen: -an irregular tender mass in lower
abdomen arising out of the pelvis.
 Abdomen may feel doughy due to matted
intestines.
 Tubercular ascites
 Per vaginam: -Vulval or vaginal ulcer presents with
undermined edges.
 Thickening of the tubes which are felt through the
lateral fornices or nodules, felt through posterior
fornix.
 Bilateral pelvic mass

101.  Leucocyte count and ESR are raised.
 Mantoux test: Positive test
 Chest X-ray ; evidence of healed or active
pulmonary lesion
 Diagnostic uterine curettage: two materials taken
1. formol-saline for histopathological examination
to detect the giant cell system.

102. 2. One part in normal saline for:
 Culture in Löwenstein-Jensen media.
 Ziehl- Neelsen’s stain (AFB-Microscopy).
 Nucleic acid amplification.
 Guineapig inoculation.

103.  Nucleic acid amplification techniques with
Polymerase Chain Reaction (PCR), can identify
M. tuberculosis from endometrium or
menstrual blood .
 Sputum and urine culture .
 Lymph node biopsy .
 Biopsy from the lesion in cervix, vagina or
vulva.
 Hysterosalpingography (HSG):
 Usg abdomen
 laproscopy

105.  CAT 1 ATT drugs for 6 months.
 Indications for surgery:-
1. Unresponsiveness of active disease in spite of
adequate anti-tubercular chemotherapy.
2. Tubercular pyosalpinx, ovarian abscess or
pyometra
3. Persistent menorrhagia and/ or chronic pelvic
pain causing deteriorating health status.

106.  Menopause means permanent cessation of
menstruation at the end of reproductive life
due to loss of ovarian follicular activity. It is the
point of time when last and final menstruation
occurs.
 The permanent cessation of menstruation. The
average age of menopause is 51years (45-
55yrs).
 The age at menopause seems to be genetically
determined, and is unaffected by race, SES,age
at menarche,or number of prior ovulations

107.  Premature menopause:menopause before
40years – incidence-1 percent
 Surgical menopause
 Natural menopause

108.  Few years prior to menopause, along with
depletion of the ovarian follicles, the follicles
become resistant to pituitary gonadotropins.
 There is a significant fall in the level of serum
estradiol from 50–300 pg/mL before
menopause to 10–20 pg/mL after menopause.
 This decreases the negative feedback effect on
hypothalamopituitary axis resulting in increase
in FSH.

109.  The increase of LH occurs subsequently.
Disturbed folliculogenesis during this period
may result in anovulation, oligo-ovulation,
premature corpus luteum or corpus luteal
insufficiency.
 Estradiol production drops down to the optimal
level of 20 pg/mL → no endometrial growth →
absence of menstruation.
 Rise in FSH is about 10–20 fold whereas that of
LH is about 3-fold. GnRH pulse secretion is
increased both in frequency and amplitude

110.  Vasomotor symptoms: last for 2 years following
menopause.
 Hot flushes, night sweats and palpitation
 Skin and hair: -There is thinning, loss of
elasticity and wrinkling of the skin.
 Skin collagen content and thickness decrease
by 1–2% per year.
 “Purse string” wrinkling around the mouth and
“crow feet” around the eyes are the
characteristics

111.  Urogenital atrophy: vaginal dryness,
dyspareunia, pruritus vulvae, urinary
frequency, urgency, and recurrent cystitis
 Psychological symptoms: irritability,
nervousness, depression, insomnia and
anxiety.
 Dementia: Estrogen is thought to protect the
function of central nervous system. Dementia
and mainly Alzheimer disease are more
common in postmenopausal women.

112. Cardiovascular and cerebrovascular effects
 Oxidation of LDL and foam cell formation
cause vascular endothelial injury, cell death
and smooth muscle proliferation.
 All these lead to vascular atherosclerotic
changes, vasoconstriction and thrombus
formation .
 Risks of ischemic heart disease, coronary
artery disease and strokes are increased.

113.  Following menopause, there is loss of bone
mass by about 3–5% per year. This is due to
deficiency of estrogen.
 Osteoporosis is a condition where there is
reduction in bone mass but bone mineral to
matrix ratio is normal.

114.  Primary (Type 1) due to estrogen loss, age,
deficient nutrition (calcium, vit. D) or hereditary
 Secondary (Type 2) to endocrine abnormalities
(parathyroid, diabetes) .
 Osteoporosis may lead to back pain, loss of
height and kyphosis. Fracture of bones is a
major health problem. Fracture may involve the
vertebral body, femoral neck, or distal forearm
(Colles’ fracture).

115. 1. Cessation of menstruation for consecutive
12 months during climacteric.
2. Appearance of menopausal symptoms ‘hot
flush’and ‘night sweats’.
3. Vaginal cytology – showing maturation
index of at least 10/85/5 (Features of low
estrogen).
4. Serum estradiol : < 20 pg/mL.
5. Serum FSH and LH : >40 mlU/mL (three
values at weeks interval required).

116.  Advise on a healthy life style
 Psychological support
 Hormone replacement therapy

117.  Lifestyle modification includes: Physical activity,
reducing high coffee intake.
 Exercise—weight bearing exercises, walking,
jogging
 ™Nutritious diet—balanced with calcium and protein
is helpful.
 Supplementary calcium—daily intake of 1–1.5 g
 ™Vitamin D—supplementation of vitamin D3 (1500–
2000 IU/day)
 ™Cessation of smoking and alcohol

118.  Bisphosphonates prevent osteoclastic bone
resorption. It improves bone density and
prevents fracture. Drug should be stopped
when there is severe pain at any site.
 Alendronate is more potent.
 Ibandronate and zolendronic acid are also
effective and have less side effects.
 Side effects include gastric and esophageal
ulceration, osteomyelitis and osteonecrosis of
the jaw.

119.  ™Calcitonin inhibits bone resorption.
Simultaneous therapy with calcium and vitamin
D should be given. It is given either by nasal
spray (200 IU daily) or by injection (SC) (50–100
IU daily). It is used when estrogen therapy is
contraindicated.
 ™Fluoride prevents osteoporosis and increases
bone matrix. It is given at a dose of 1 mg/kg .
Calcium supplementation should be continued.

120.  Selective estrogen receptor modulators
(SERMs) are tissue specific in action.
 Raloxifene has shown to increase bone
mineral density, reduce serum LDL and to
raise HDL2 level. Raloxifene inhibits the
estrogen receptors at the breast and
endometrial tissues

121.  Clonidine, an alpha adrenergic agonist may be
used to reduce the severity and duration of hot
flushes.
 ™Thiazides reduce urinary calcium excretion. It
increases bone density specially when
combined with estrogen.
 ™Paroxetine, a selective serotonin reuptake
inhibitor, is effective to reduce hot flushes .
 ™Gabapentin is an analog of gamma-
aminobutyric acid. It is effective to control hot
flushes.

122.  Relief of menopausal symptoms.
 Prevention of osteoporosis
 To maintain the quality of life in menopausal
years.
 HRT for a short period of 3–5 years have been
advised.

123.  Special group of women to whom HRT should
be prescribed:
1. ••Premature ovarian failure
2. ••Gonadal dysgenesis
3. ••Surgical or radiation menopause

124.  Undiagnosed genital tract bleeding
 ™Estrogen dependent neoplasm in the body
 ™History of venous thromboembolism
 ™Active liver disease
 ™Gallbladder disease
 Existing breast cancer
 Existing endometrial cancer

125.  Women who have had a hysterectomy only
need to take oestrogen
 Women with an intact uterus must take
progestogen for endometrial protection to
prevent endometrial cancer or hyperplasia
 Regular surveillance of endometrium is
required for women (extreme intolerance of
progestogen) on unopposed oestrogen

126.  Sequential preparation: progestogen added for
12-14 days each month. Some women will not
bleed on sequential preparations and this is not a
cause for concern provided that the progestogen
is taken correctly.
 Continuous combined HRT: give oestrogen and
progestogen daily. These preparation induces
endometrial atrophy. Intermittent bleeding and
spotting are common in the first few month of
use. More suitable for women who are at least
one year since their last spontaneous period.

127.  Oral estrogen regime: Estrogen—conjugated
equine estrogen 0.3 mg or 0.625 mg is given
daily for woman who had hysterectomy.
 Estrogen and cyclic progestin: For a woman
with intact uterus estrogen is given
continuously for 25 days and progestin is
added for last 12–14 days.

128.  Continued combined therapy can prevent
endometrial hyperplasia.
 ™Subdermal implants: Implants are inserted
subcutaneously over the anterior abdominal wall
using local anesthesia. 17 β estradiol implants
25 mg, 50 mg or 100 mg are available and can
be kept for 6 months.
 ™Percutaneous estrogen gel: 1 g applicator of
gel, delivering 1 mg of estradiol daily, is to be
applied onto the skin over the anterior
abdominal wall or thighs. Effective blood level of
oestradiol (90–120 pg/mL) can be maintained.

129.  Transdermal patch: It contains 3.2 mg of 17 β
estradiol, releasing about 50 μg of estradiol in
24 hours. Physiological level of E2 to E1 is
maintained.
 It should be applied below the waist line and
changed twice a week.
 ™Vaginal cream: Conjugated equine vaginal
estrogen cream 1.25 mg daily is very effective
specially when associated with atrophic
vaginitis.

130.  Progestins: In patients with history of breast
carcinoma, or endometrial carcinoma, progestins
may be used. It may be effective in suppressing
hot flushes and it prevents osteoporosis.
 Medroxyprogesterone acetate 2.5–5 mg/day
 ™Tibolone: Tibolone is a steroid (19-
nortestosterone derivative) having weakly
estrogenic, progestogenic and androgenic
properties.
 It prevents osteoporosis, atrophic changes of
vagina and hot flushes. A dose of 2.5 mg per day
is given.

131.  Harrison text book
 DC datta gynecology
 Shaws gynecology